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  1. 1. Seizure & Epilepsy<br />
  2. 2. Definitions<br />
  3. 3. Seizure<br />A sudden surge of electrical activity in brain that usually affects how a person feels or acts for a short time.<br />Some seizures can hardly be noticed, while others are totally disabling.<br />
  4. 4. Epilepsy<br />A condition that affects central nervous system (CNS)<br />had at least 2 seizures <br />not caused by some known medical condition like alcohol withdrawal or extremely low blood sugar.<br />not indicate anything about the cause of the seizures, what type they are, or how severe they are.<br />
  5. 5. Momentary loss of consciousness<br /> Fit<br /> Faint<br /> Fake<br />
  6. 6. Transient loss of consciousness<br />History and Physical<br />Witness account<br />Déjà vu<br />Jamais vu<br />Aphasia<br />Olfactory aura<br />Epigastric sensation<br />Tongue biting<br />Post event delirium<br />Focal neurodeficit<br />Light-headedness<br />Sweating<br />Prolonged standing<br />Precipitants <br /> eg.micturition<br />Chest pain<br />Palpitation<br />Slow heart rate<br />Low blood pressure<br />Aphasia<br />Delirium<br />Head turn<br />Automatism<br />Posturing<br />Convulsion<br />Postictal <br />delirium<br />Myoclonus <br />or convulsion<br />after pallor,<br />sweating <br />and <br />collapse<br />Pallor<br />Sweating<br />Slow pulse<br />Low BP<br />Convulsive <br />syncope<br />Seizure<br />Syncope<br />Syncope<br />Seizure<br />
  7. 7.
  8. 8.
  9. 9. Nonepileptic causes for spells<br />Physiologic<br />Tremor<br />Vasovagal syncope<br />Cardiac arrhythmias<br />Migraine<br />Medication adverse effects<br />Transient ischemic attacks<br />Autonomic dysfunction <br />
  10. 10. Nonepileptic causes for spells<br />Psychologic<br />Anxiety<br />Panic attacks<br />Mood disorder<br />Personality disorder<br />Psychosis<br />Somatiform illness<br />Psychogenic seizures<br />
  11. 11. Phase of seizures<br />Preictal phase or aura or warning<br />Ictal phase : simple or complex partial or generalized tonic-clonic seizure<br />Postictal phaseor recovery period : last from seconds to minutes to hours<br />
  12. 12. Precipitants of seizure<br /> Sleep and lack of sleep<br /> Drugs and alcohol<br /> Intercurrent illness : infection, <br /> electrolyte imbalance<br /> Menstruation<br /> Stress and worry<br /> Other precipitants-reflex epilepsy<br />
  13. 13. Classification of seizure<br />Partial (focal, localized) seizures<br />Generalized seizures (convulsive or non-convulsive)<br />Unclassified epileptic seizures<br />
  14. 14. Partial (focal, localized)seizures<br />Simple partial seizures (preserved consciousness)<br /> Complex partial seizures (impaired consciousness)<br /> Partial seizures evolving to secondarily <br /> generalized seizures<br />
  15. 15. Simple partial seizures <br /> (preserved consciousness)<br />With - motor signs<br /> - somatosensory or special <br /> sensory systems<br /> - autonomic symptoms or signs<br /> - psychic symptoms<br />
  16. 16. Complex partial seizures (impaired consciousness)<br /> - Simple partial onset followed by impairment of conscious<br /> - With impairment of consciousness at onset<br />
  17. 17. Partial seizures evolving to secondarily generalized seizures<br /> - Simple partial seizures evolving to generalized seizures<br /> - Complex partial seizures evolving to generalized seizures<br /> - Simple partial seizures evolving to complex partial seizures evolving to generalized seizures <br />
  18. 18. Generalized seizures (convulsive <br /> or nonconvulsive)<br />- Absence seizures<br /> Typical absences<br /> Atypical absences<br />- Myoclonic seizures<br />- Clonic seizures<br />- Tonic seizures<br /> - Tonic-clonic seizures<br /> - Atonic seizures (astatic seizures)<br />
  19. 19. Unclassified epileptic seizures<br /> - Neonatal seizures<br /> - Recurrent status epilepticus<br /> - Rare or ‘isolated’ seizures<br />
  20. 20. Epileptic seizure<br />All clinical and<br />laboratory data<br />neuroimaging<br />Seizure<br />description <br />and EEG<br />Etiology<br />Seizure<br />type (s)<br />
  21. 21. Seizure<br />Idiopathic <br />Generalized<br /> epilepsy likely<br />Features <br />of focal <br />epilepsy<br />Epilepsy <br />or PNES<br />Provoked<br /> seizures<br />Treat <br />cause <br />+/- AED<br />EEG<br />EEG<br />MRI/CT <br />brain<br />Video <br />EEG<br />PNES=psychogenic non-epileptic seizures<br />AED=antiepileptic drug<br />
  22. 22. Laboratory investigation<br />CBC<br /> FBS, BUN, Creatinine<br />Electrolyte , Liver function test , Ca+2 Mg+2<br />Electro-encephalography (EEG)<br />Video EEG<br />Neuroimaging : CT Scan, MRI, MR Spect, PET<br />Special investigation : ammonia, lactate, <br /> pyruvate etc.<br />
  23. 23. Electroencephalogram<br />
  24. 24. What value is the EEG?<br /><ul><li>Add weight to the clinical diagnosis
  25. 25. Aid classification of epilepsy
  26. 26. Detection of the structural brain lesion.</li></li></ul><li>EEG<br />30 minute interictal EEG –useful when clinical suspicion of epilepsy<br />Timing is important<br />Within 24 hr of generalized convulsion: 50% have abnormal EEG <br />First 48 hr: 21-34% have epileptiform activity<br />Sleep EEG or sleep-deprived EEG might increase diagnostic yield<br />
  27. 27. Normal EEG<br />
  28. 28. Primary generalized epilepsy—ictal EEG<br />
  29. 29. Primary generalized epilepsy- interictal EEG<br />
  30. 30. Burst of generalized spike and wave discharges—typical absence seizure<br />
  31. 31. EEG monitoring<br />
  32. 32. Video Monitoring<br />Helpful in determining nature of seizure disorder (epilepsy, convulsive syncope, or psychogenic seizures)<br />
  33. 33. Indication for neuroimaging in patients with seizures<br />Partial seizure<br /> Late onset unprovoked seizure (age > 25)<br /> Unexplained neurological signs<br /> Focal slow waves EEG<br /> poor control or new symptoms / signs<br />
  34. 34. Neuroimaging<br />In the absence of trauma: CT and MRI brain for patients presenting with suspected first unprovoked seizure or with a focal neurological deficit.<br />MRI is preferable for looking for neuronal migrational disorders, major malformations, vascular anomalies, tumors<br />
  35. 35. The causes of epilepsy<br />Genetic factor<br />Congenital abnormalities<br />Trauma and the effect of craniotomy<br />CNS infection<br />Cerebrovascular disease<br />Cerebral tumors<br />Alzheimer’s disease and other degenerative <br />disease<br /> Others<br />
  36. 36. Neurocysticercosis<br />
  37. 37. Cerebral infarction<br />
  38. 38. Intracerebral hemorrhage<br />
  39. 39. Brain tumor or metastasis<br />
  40. 40. Lt mesial temporal sclerosis<br />
  41. 41. Cortical dysplasia<br />
  42. 42. 52 year old woman with intractable seizure<br />PET scan<br />
  43. 43. PET using F-18 FDG-- Decreased FDG uptake in both temporal lobes, right worse then left but otherwise relatively symmetric<br />
  44. 44. What to do?<br />Generalized seizure<br />Loosening the patient’s clothing<br />Lower the patient gently to the floor, turn them onto their side and cushion head<br />Nothing is put into the mouth<br />Remove any items that could cause injury<br />
  45. 45. What to do? ---Generalized seizure<br />When the seizure is over, allow the patient to rest or sleep<br />If they are able to return to their feet, help them home<br />Obtain medical help if they continue to experience breathing problems once the seizure is over, or if the seizure lasts a long time(over 10 mins), or when another attack quickly follows the first<br />
  46. 46. What to do?<br />Partial seizures<br />Stay with the patients throughout the seizure<br />Protect them from any dangerous object<br />Taking care not to restrain them in anyway<br />
  47. 47. First aids<br />
  48. 48. Treatment<br />
  49. 49. จะต้องให้ยากันชักหรือไม่?<br />รักษา<br />ไม่รักษา<br />ผลข้างเคียงของยา<br />โอกาสจะชักซ้ำ<br />
  50. 50. Choose a drug : considering the following factors<br />The seizure type and prognosis<br /> Age<br /> The possibility of pregnancy<br /> Toxicity <br /> Drug interaction<br /> Price<br />
  51. 51. RISK OF RECURRENT SEIZURE<br />The recurrence risk follow a first unprovoked seizure 27%-52%<br />50% recurrence occur within 6 months <br />over 80% within 2 years of initial seizures<br />twice as likely to have another seizure if you have a known brain injury or brain abnormality.<br />
  52. 52. RISK OF RECURRENT SEIZURE(cont)<br />If you do have two seizures, there's about <br />80% chance that you'll have more.<br />
  53. 53. Factors predictive of a high rate of seizure recurrence after the first unprovoked seizure<br /><ul><li>Abnormal neurologic status by NE or imaging
  54. 54. EEG abnormalities (especially epileptiform)
  55. 55. Partial seizures</li></li></ul><li>Counseling before treatment<br />1. Aims of treatment<br />2. Prognosis and duration of the <br /> expected treatment<br />3. Importance of compliance<br />4. Side effects<br />
  56. 56. Starting antiepileptic treatment<br />Prospective risks Usual clinical Factors that may modify<br /> of epilepsy practice usual practice <br /> Single seizure No treatment Progressive cerebral disorder<br /> (clinically Dx) Clearly epileptic EEG<br /> 2 or more seizure Monotherapy Seizures widely separated<br /> (clinically Dx) in time (> 1 year)<br /> Identified precipitating,<br /> factors (eg, drugs, alcohol,reflex stimuli) <br /> Probability of poor compliance (eg, personality disorder)<br /> Attitude of patients/parents<br />
  57. 57. More<br />Antiepileptic drugs<br />20<br />Pregabalin<br />Levetiracetam<br />Oxcarbazepine<br />Tiagabine<br />Fosphenytoin<br />15<br />Topiramate<br />Gabapentin<br />Felbamate<br />Lamotrigine<br />Zonisamide<br />10<br />Vigabatrin<br />Sodium Valproate<br />Carbamazepine<br />Benzodiazepines<br />Ethosuximide<br />5<br />Phenytoin<br />Primidone<br />Phenobarbital<br />Bromide<br />0<br />1840<br />1860<br />1880<br />1900<br />1920<br />1940<br />1960<br />1980<br />2000<br />Calendar year<br />Antiepileptic Drug Development<br />
  58. 58. First-line choice of AEDs according to seizure type<br />
  59. 59. Advantages of Monotherapy<br />Better seizure control<br />Reduced side effects<br />Absence of drug interactions<br />Reduced teratogenic effects<br />Better compliance<br />Reduced cost of medication<br />Improved quality of life <br />
  60. 60. Expected outcomes of AED therapy<br />Well <br />controlled <br />65%<br />Unsatisfactorily<br />controlled <br />35%<br />Monotherapy<br />Well <br />controlled <br />10%<br />Unsatisfactorily<br />controlled <br />25%<br />Add-on therapy<br />Unsatisfactorily<br />controlled <br />20%<br />Well <br />controlled <br />5%<br />Multiple drug therapy<br />
  61. 61. Managing newly diagnosed epilepsy<br />Newly diagnosed epilepsy<br />47%<br />Seizure free<br />First drug<br />13%<br />Seizure free<br />Second drug<br />Refractory<br />Surgical assessment<br />Rational duotherapy<br />
  62. 62. Adverse effect of AED<br /><ul><li>Dose related
  63. 63. Idiosyncratic / allergic
  64. 64. Chronic toxicity
  65. 65. Teratogenicity</li></li></ul><li>Older AEDs<br />
  66. 66. AED interactions<br />CBZ : autoinduction, VPA, PHT, -PB<br />PHT : CBZ, VPA, PB <br />PB : CBZ, VPA, PHT<br />VPA : CBZ, PB, PHT<br />
  67. 67. AEDs<br />Drug interaction with AED and other drugs: via effect on hepatic CYP450 enzyme system<br />PB, primidone, PHT, CBZ induce CYP enz. :<br /> Accelerate breakdown of many prescribed lipid-soluble drugs metabolized by the same system: OCP, cytotoxic, antiarrythmic, warfarin<br />VPA is a weak CYP enz. Inhibitor: <br /> Slow clearance of other AEDs such as PHT, LTG. <br />Newer AEDs : less likely to interfere with hepatic metabolism.<br />GBP, LEV,PGB,VGB do not undergo hepatic metabolism<br />
  68. 68. Newer AEDs<br />Adjunctive treatment of refractory epilepsy<br />Some of these AEDs: LTG, GBP, OXC, TPM have also demonstrated efficacy as monotherapy<br />
  69. 69. Effects of phenytoin levels<br />Level (mg/ml) Effect<br />0-10 Subtherapeutic<br />10-20 Therapeutic<br />20-30 Mild toxicity; nystagmus, mild ataxia30-40 Moderate toxicity ; ataxia prominent<br />> 40 Severe toxicity; ataxia, conscious -<br /> ness, encephalopathy<br />
  70. 70. Potential Causes of Treatment Resistant Epilepsy<br />Diagnostic errors:<br />Non-epileptic events   <br />Wrong diagnosis of seizure types/ epileptic syndrome   <br />Missing of underlying causes/lesions<br />Patient’s errors:<br />Non-compliance   <br />Inappropriate life style, inappropriate metabolism <br />
  71. 71. Potential Causes of Treatment Resistant Epilepsy<br />Treatment errors:<br />Wrong choice of drugs <br />Less optimal doses of drugs  <br />Inadequate dosing schedules<br />Antiepileptic drug toxicity <br />Disease itself:<br />Treatment resistant epilepsy<br />metabolic disorder<br />
  72. 72. Stopping antiepileptic treatment<br />Absolute requirement<br />2-3 years free of all seizures<br /> Patient’s informed agreement<br />
  73. 73. Factors in favour<br /><ul><li>Childhood epilepsy
  74. 74. Primary generalized epilepsy
  75. 75. Absence of cerebral disorder
  76. 76. Short duration of epilepsy
  77. 77. Normal EEG
  78. 78. Non-driver</li></li></ul><li>Adverse prognostic factors<br />Symptomatic etiology, identifiable brain pathology<br /> Partial-onset seizures or Atonic seizures<br /> Late-onset or first-year epilepsy <br /> Specific epilepsy syndrome (particularly JME) <br /> Abnormal EEGs<br /> Multiple seizure types in the same patient<br /> Additional mental or motor handicap<br /> Long duration or severe epilepsy prior to treatment <br /> Poor initial response to treatment<br />
  79. 79. Features common to the surgically privileged seizure disorders<br />Presence of a well-circumscribed structural lesion on the MRI (lesional epilepsy)<br />Presence of well-localized interictal epileptiform discharged on the EEG<br />Clinical features of habitual seizures indicating focal onset<br />Absence of discordance between above feature<br />Focus localized by above features is surgically accessible and involves little or no eloquent cortex<br />Absence of other potentially epileptogenic abnormalities<br />
  80. 80. Status epilepticus<br />A condition in which epileptic activity <br />persists for 30 minutes or more<br />
  81. 81. Common etiologies for status epilepticus in children and adolescents<br />Idiopathic<br />Acute symptomatic<br />Electrolyte disturbance<br />Encephalitis<br />Head trauma<br />Remote symptomatic<br />Past stroke<br />CNS infection<br />Cerebral palsy<br />Progressive encephalopathy<br />Tuberous sclerosis<br />Other neurodegeneration<br />Febrile<br />
  82. 82. Status epilepticus management<br />
  83. 83.
  84. 84.
  85. 85. Epilepsy and pregnancy<br /> Seizure control<br /> Obstetric complication<br /> Neonatal outcome<br />
  86. 86. Neonatal outcome<br />Risk of seizure <br /> (3 times > normal population)<br />developmental outcome<br />congenital anomalies 4-8% <br /> (2-3 times > normal population)<br />
  87. 87. The most common malformation<br />Congenital heart disease<br />orofacial cleft<br />neural tube defect<br />intestinal atresia<br />urogenital defects<br />Neural tube defect<br />
  88. 88. Fetal antiepileptic drug syndrome (minor anomalies)<br />Facial dysmorphism<br /> Distal digital hypoplasia<br /> Developmental delay<br /> Mental deficiency <br />
  89. 89. Factors affecting neonatal outcome<br />AED <br />genetics <br />folic acid<br />socioeconomic<br />maternal health<br />
  90. 90. Recommendations for managing Women With Epilepsy<br />Before Conception<br />Educate the family regarding risks<br />Review classification of epilepsy <br />Determine most appropriate medicine for seizure control <br />
  91. 91. Determine need for continued medication <br /> - may discontinue if seizure-free for 2 or more years <br /> - do not discontinue medication if epilepsy syndrome <br /> suggests continued need for treatment<br />Reduce medicines to monotherapy, lowest dose possible <br />Start folic acid 1 mg/day<br />Eliminate other risk factors – smoking, drugs, alcohol <br />
  92. 92. After conception<br />Do not change antiepileptic medication <br />Refer for prenatal care <br />Prescribe vitamins, including folic acid <br />Check ‘free’ drug levels every trimester and change doses as needed <br />Evaluate for neural tube defects at 12 to 16 weeks (ultrasound, alpha-fetoprotein, amniocentesis) <br />
  93. 93. Consider vitamin K predelivery <br />Check antiepileptic drug levels prior to delivery and increase doses if needed<br />
  94. 94. After Delivery<br />Check levels <br />Examine infant <br />
  95. 95. ควรคลอดโดยวิธีใด ?<br /> ถ้าไม่มีข้อห้าม สามารถคลอดทางช่องคลอด แต่อาจช่วยคลอดเมื่อมีข้อบ่งชี้<br />