description about types, treatment and management of epilepsy

1. EPILEPSY
DR.MALIHA

2. DEFINATION
Term epilepsy is derived from the Greek word
Epilepsia” which means ‘to be seized’, ‘to be taken
hold of’, or ‘to be attacked’
Epilepsy: A condition in which a person has
recurrent seizures due to chronic, underlying process
Characterized by,
 Recurrent seizures –
 Loss of consciousness
 With or without body movements

3. CLINICAL DEFINITION
 Epilepsy – a predisposition to having 2 or
more unprovoked seizures in 24 hours
 Seizure; Sudden, involuntary, usually time-
limited alteration in behavior, including motor
activity, autonomic function, consciousness, or
sensation.
 Caused by abnormal electrical discharges of
neuronal circuits

4. MECHANISM OF SEIZURE
1. Mutation ; in voltage gated channels, ligand gated
channels and other proteins.
2. Epileptogenesis ; mechanism through which
brain or part of brain become epileptic.
3. Paroxysmal depolarization shift
Sudden Depolarization series of AP After-
Hyperpolarization(K ,GABA)
Cl- channel open disrupted sufficient neuron
inhibitory neuron lost and excitatory neuron fires at same
time seizure

5. CAUSES
 Idiopathic (70 – 80%) – cause unknown but presumed
genetic
 Secondary
 Cerebral dysgenesis /malformation
 Cerebral vascular occlusion
 Cerebral damage
-Antenatal: Congenital infections, drugs, alcohol
. -Natal: HIE, birth trauma
- Postnatal: IVH in prematurity, CNS infections,
kernicterus, trauma.
 Cerebral tumors
 Neurodegenerative disorders
 Neurocutaneous syndrome

7. CLASSIFICATION

9. TONIC- CLONIC SEIZURES(GRAND MAL
EPILEPSY)
1.Aural stage; which may be sensory or motor
2.Tonic stage;
 Onset is abrupt with tonic spasm
 Pt loses consciousness and may fall on ground
 Facial pallor ,up rolling of eye ,pupil dilated ,conjunctiva
become insensitive, tongue biting , muscles become
stiff. This stage lasts for 10-20 seconds
3.Clonic stage; is characterize by shaking of trunk and
extremities and frothing in mouth. phase lasts for 30 sec
4.Postictal stage; Pt exhausted and confused going to
sleep for many hours
 Transient paralysis may occur (Todd's paralysis)

10. CLINICAL AND EEG FINDING

11. ABSENCE SEIZURE( PETIT MAL EPILEPSY)
1.Typical absence seizure start at 5-8 year of age
and disappear after puberty.
 Do not have an aura.
 Seizure consist of transient loss of consciousness ,
vacant stares, up rolling of eye, blinking and nodding of
head . Followed by resumption of work as before
seizure.
 EEG as generalized 3 per sec . spike & wave pattern.
2.Atypical absence seizure consist of myoclonic
components and tone changes of head and body
 Associated with 1-2 Hz spike and slow discharge
3.Juvenile absence seizure similar to typical seizure
but 4-5 Hz spike

12. CLINICAL AND EEG FINDING

13. MYOCLONIC EPILEPSY
 It is characterize by frequent recurrence of brief minor
seizure , brief muscle contraction and atonia resulting in
multiple falls.
 It is associated with mental retardation and is resistance
to drug . Having several forms;
 Benign myoclonus of infancy ;having myoclonic
movements confine to neck , trunk and extremities .
EEG is normal
 Typical myoclonic epilepsy of early childhood;
 Mean age is 2-4 years .1/3 children have +ve family
history . EEG shows fast spike wave complexes>2.5Hz
.Prognosis is good.
 Progressive myoclonic epilepsy; progressive
dementia and myoclonus.
 Prognosis is poor.

14. MYOCLONIC……..
 Complex myoclonic epilepsy;
 1/3 have delayed developmental milestone .
 Hx of HIE may present.
 Generalized upper motor and extrapyramidal sign with
microcephaly .
 Prognosis is poor.
 Juvenile myoclonic epilepsy(Janz syndrome)
 It occur at12-16 years.
 Child experience frequent myoclonic jerks on
awakening. After some years early morning generalized
tonic- clonic seizures develop in association with
myoclonus.
 Neurological examination is normal.

16. 1.SIMPLE PARTIAL SEIZURE
 Focal seizure without impairment of consciousness
 Specific nature which gives clue of location of
seizure.
 Brief motor seizure include focal tonic , clonic or
atonic seizure.
2.Complex Partial Seizure
 Focal seizure with impairment of consciousness
 It usually last 1-2 min and are preceded by aura .

17. SIMPLE PARTIAL SEIZURES

18. COMPLEX PARTIAL SEIZURES

19. INFANTILE SPASMS
 3 to 9 month of age.
 Brief symmetrical contractions of neck, trunk ,
extremities , sudden dropping of head & flexion of
arms - ‘Salaam fit’
 EEG- Hypsarrhythmic pattern – diffuse high voltage
slow spike and chaotic activity

20. INFANTILE SPASM …….
1. Cryptogenic -10-20% cases - Normal birth Hx -
Normal development - Neurologic exam, CT,MRI
head normal - No risk factors
2. Symptomatic- 80-90% cases Related to brain
damage from prenatal insult ,HIE, cong infections,
inborn errors of metabolism, , Cong anomalies of
brain Post natal insult, infections, head Trauma, 80-
90% MR

21. LENNOX –GASTAUT SYNDROME
 Onset –late infancy or childhood
 Mixed seizure- myoclonic, atypical absence
,generalized tonic-clonic, partial
 Prognosis unsatisfactory
Triad;
1.Atypical absences, axial tonic seizures, drop
attacks
2. Typical EEG pattern - Slow spike and waves on
awake EEG & 10Hz bursts during sleep
3.Psychomotor retardation

22. APPROACH TO THE PATIENT
 History and physical - emphasis on seizure event is
most valuable tool
 Lab tests - CBC, metabolic profile.
 Electroencephalogram(EEG) –
To correlate with seizure activity and electrical discharges
in the brain
 Spinal tap for CSF analysis
 Brain imaging studies – CT and MRI
 PET and SPECT; To detect areas of hypometabolism in
epileptogenic lesions.
 Genetic studies.

23. TREATMENT
1. Deciding of long term therapy
2. Counseling

24. PRINCIPLES OF ANTICONVULSANT
THERAPY
 Treatment recommended if ≥ 2 episodes→ recurrence
risk 80%
 Attempt to classify the seizure type & epileptic
syndrome
 Monotherapy as far as possible → most appropriate
drug → increase dose gradually till epilepsy controlled,
maximum dose reached .
 Alternative monotherapy (Add on the 2nd drug if 1st
drug failed. Optimize 2nd drug, then try to withdraw 1st
drug.
 Rational combination therapy (usually 2 or maximum 3
drugs )
 Combines drugs with different mechanism of action &
consider their spectrum of efficacy, drug interactions &
adverse affects.

25.  Monitor drug levels to check compliance → if
seizures not well controlled/in situations of
combination therapy where drug interaction is
suspected.
 When withdrawal of medication is planned →
seizure free for 2 years . Then attempting slow
withdrawal of medication over 3-6 months .
 If seizures recur → last dose reduction is
reversed & medical advice sought.

26. ADVICE FOR PATIENTS/PARENTS
 Educate and counsel on epilepsy.
 Emphasize compliance if on anticonvulsant.
 Don’t stop the medication by themselves . this may
precipitate breakthrough seizures.
 In photosensitive seizures-watch TV in brightly lit
room . avoid sleep deprivation.
 Use a shower with bathroom door unlocked.
 No cycling in traffic , climbing sports or swimming
alone.
 Know emergency treatment for seizure.
 Inform teachers and school about the condition.

27. CHOICE OF DRUG
 Drug of first choice
 Focal seizure ; oxcarbazepine and carbamazepine
 Absence seizure; ethosuximide
 Juvenile myoclonic epilepsy; Valporate nd
lemotrigene
 Lennox- Gastaut syndrome ; clobazam , valporate ,
topiramate , lamotrigine, and rufinamide
 Infantile spasm ;adrenocorticotropic hormone
(ACTH)

30. ADJUNCTIVE T WHEN S POORLY
CONTROLLED
 Gabapentine , clobazam , lamotrigine, topiramate
, vigabatrin
Surgical Rx -Resection of corpus callosum,
 Focal resection of parts of cerebral cortex involved
as epileptic foci.

31.  Recommended
for refractory
seizure
 Ketosis raises
the seizure
threshold
 Diet consist of
3:1 or 4:1

32. INTRACTABLE /REFRACTORY EPILEPSY
Re- evaluate the following possibilities
 Is it a seizure /non epileptic event ?
 Anticonvulsant dose not optimized.
 Poor compliance to anticonvulsant
 Wrong classification of epilepsy syndrome →
wrong anticonvulsant .
 Anticonvulsant aggravating seizures.
 Lesional epilepsy, hence a potential epilepsy
surgery candidate .
 Progressive epilepsy or neurodegenerative
disorder.